Structure and process of dementia care and patient outcomes after hip surgery in elderly people with dementia: A retrospective observational study in Japan

Background: Japan introduced the financial incentives for dementia special care at hospitals in the fee schedule in April 2016. Objective: To investigate whether the financial incentives for dementia special care contributed to better patient outcomes after hip surgery for older adults with dementia. Design: Retrospective observational study using the Diagnosis Procedure Combination database and the Reporting on medical functions of hospital beds data. Setting: Acute care hospitals adopting the Diagnosis Procedure Combination system in Japan. Participants: A total of 20,393 eligible patients aged 65 years or older with dementia who underwent hip surgeries and discharged from 405 hospitals from April 2016 to March 2017. Methods: There are two levels of dementia care quality categories in the financial incentives for dementia special care as follows: Type 1 requires a multidisciplinary team with geriatric and dementia care expertise and Type 2 requires to assign trained nurses who underwent dementia training at every general ward. The outcomes were in-hospital mortality, readmission within 30 days, and length of hospital stay. We performed generalized estimating equation model or logistic generalized estimating equation models adjusting for individual and hospital characteristics. Results: Among the 405 hospitals, the numbers of hospitals without dementia care incentive, those with Type 1, and those with Type 2 were 207, 99, and, 99, respectively. Overall, the prevalence of in-hospital death and readmission within 30 days was 2.01% and 2.70%, respectively. Overall, the mean (standard deviation, SD) length of hospital stay was 32.0 (20.0) days. There were no significant associations between dementia special care and in-hospital mortality in Type 1 (adjusted OR [odds ratio] =0.87, 95% confidence interval [CI]=0.66-1.16) and Type 2 (adjusted OR=1.18, 95% CI = 0.92-1.52), and readmission within 30 days in Type 1 (adjusted OR=1.11, 95% CI=0.89-1.38) and Type 2 (adjusted OR= 1.03, 95% CI=0.831.29). Length of hospital stay was not significantly different among hospitals with and without incentive, Type 1 (coefficient -0.23, 95% CI=-2.64-2.18.), and Type 2 (coefficient 0.87, 95% CI=-1.54-3.28). An increase in patient-to-nurse ratio was significantly associated with 2.25 days longer length of hospital stay (95% CI 1.00-3.51). Conclusion: Dementia care incentive was not associated with better outcomes in elderly with dementia who underwent hip surgery in Japan, but the worse nurse workload was associated with longer length of hospital stay. Further long-term assessment is necessary. (C) 2019 Elsevier Ltd. All rights reserved.